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Published April 25, 2019

Last Chance to Apply for Medicare Bundled Payment Program

Since its launch last year, Medicare’s voluntary episodic payment model—Bundled Payment for Care Improvement Advanced (BPCI-A)—has become one of CMS’ most successful alternative payment models.  In BPCI-A, providers can gain critical experience in risk-based contracting on a manageable scale.

Providers now have until June 24, 2019, to apply to participate in BPCI-A starting January 1, 2020.  CMS does not intend to accept applications for 2021 or 2022, so this will be the last chance to explore this opportunity for a while.

PYA’s experienced consultants can help you analyze the BPCI-A opportunity, explore financial arrangements with other providers, complete the formal application, and analyze data to identify the episodes with the greatest likelihood for success.

Like other episodic payment models, BPCI-A participants assume the risk for the total cost of a 90-day episode of care anchored by an inpatient admission or outpatient procedure.  If the actual cost is less than a pre-determined target price, CMS will pay the difference to the participant.  If the actual cost is higher, however, the participant must pay the difference to CMS.  The amount of both payments—from CMS and to CMS—is subject to an upper limit.

The application due June 24 is not a commitment to participate in the program.  Instead, it is an opportunity to receive from CMS historical claims data and benchmarks to evaluate in which of the 33 inpatient and 4 outpatient clinical episodes to participate, if any.

CMS has not yet announced the timeline for providing this information to applicants.  An applicant will have a specified time period to review this data and return a signed participant agreement with its selected episodes.  The applicant is under no obligation unless, and until, it signs the formal agreement.

Completing the initial application is relatively easy; the challenge is deciding which entity should apply in what capacity.

An acute care hospital or physician practice group may participate in BPCI-A as a non-convener or a convener.   As a non-convener, a hospital or group is responsible only for the episodes it initiates.  For a hospital, this would include inpatient admissions; for a group, this would include inpatient admissions or outpatient procedures for which a physician in the group is the attending or operating physician.

As a convener, a hospital or practice also is responsible for episodes attributed to those hospitals or practices with which the convener has entered into formal arrangements.  Other types of entities—such as a management company or a post-acute care provider—also can participate as conveners.

Although CMS will contract only with a participant—either as a convener or a non-convener—participants may enter into arrangements with other providers to share the risks and rewards, subject to specific requirements.  These arrangements are intended to incentivize providers to participate in one or more of the pathways to success identified by CMS:  patient education, data and dashboards, care navigation, multidisciplinary steering committees, standardized care protocols, and post-acute care preferred provider networks.

Given the experience in last year’s BPCI-A application cycle, we expect management companies will aggressively recruit providers to participate in their BPCI-A programs.  These national conveners offer standardized support services in exchange for a healthy cut of any distribution.  We encourage providers to consider a more customized approach, working with a trusted adviser to develop and execute tailor-made strategies for success.

For example, PYA’s team of post-acute care experts—led by the former Health & Human Services Assistant Secretary for Aging, Kathy Greenlee—can help you optimize discharge planning for selected episodes, identify and manage high-value post-acute partners, and pursue creative community-based solutions.  Each part of this post-acute strategy is custom-built to the unique needs and circumstances of your organization and community—versus a one-size-fits-most solution.

Even if you’re not wholly committed to participating in BPCI-A, the opportunity to receive and review data relating to benchmark pricing for key episodes of care makes the application process worthwhile.  To discuss your BPCI-A opportunity, contact a PYA executive below at (800) 270-9629.

Access additional reading and background on BPCI-A.


© 2019 PYA

No portion of this article may be used or duplicated by any person or entity for any purpose without the express written permission of PYA.

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